Memorandum by Professor John Yates
CONSULTANTS'
CONTRACTS, POLITICIANS'
DILEMMA AND
PATIENTS' INEQUITY
(CC 2)
INTRODUCTION
1. There are two compelling reasons for re-examining
the basis of the consultants' contract. Firstly, there has been
a longstanding unresolved political dilemma—"Should
consultants be paid a reasonable and comparatively high salary
or does the NHS simply offer a less than adequate salary that
can be supplemented by undertaking private practice both during
the normal working week and out of hours?" Secondly, and
probably consequential to the current arrangement, "Is there
any link between the contract and the long and unfair waiting
times experienced by many patients?" Patients contrast the
longstanding political promise that offers access to health care
determined by need rather than the ability to pay, with the reality
that consistently flies in the face of the promise.
2. In one outpatient clinic this month a
patient called Keith discovered that he required heart surgery.
The surgeon explained that ideally the operation should be performed
soon, but as his condition was not urgent he would have to wait
about nine months. For a payment of £10,000 the same surgeon
would operate on him within two weeks in the same NHS hospital
or in a private hospital in a neighbouring city some 25 miles
away. His position is not an isolated example. A telephone call
to the College of Health Helpline revealed that no shorter waiting
times for routine patients were available anywhere else in England
for the type of heart surgery that Keith requires.
3. The health care system in this country
will consistently allow other patients to be treated before Keith.
They will be operated on by NHS surgeons, both in NHS hospitals
and private hospitals, even though their need is not greater.
In the NHS hospital that Keith is waiting to enter, one cardiac
patient in every 20 is a private patient. This means that Keith
will probably be overtaken by 45 private patients in nine months
in that hospital. Their operations will be performed by NHS surgeons
in NHS theatres supported by expensive intensive care facilities
and staff. Their earlier access to care will simply be based on
their ability to pay.
4. The extent to which the consultants'
contractual conditions contribute to this inequity is uncertain.
It is fairly clear that long waiting times are not solely caused
by this issue and that resource shortages, boundary definition
and inefficiency are very significant joint causes. The consultants'
contract may be one associated factor. The consultants' contract
may, on the other hand, be seen as a major cause of inequitable
waiting. Queue jumping is really only possible where payment is
made to surgeons.
5. The fact is that despite successive calls
for clarity regarding the interface between the NHS and the private
sector we still know far too little about the apportionment of
consultant workload and time between the NHS and the private sector.
AN EXAMINATION
OF POLICY—IS
IT SIMPLY
UNCLEAR OR
DELIBERATELY AMBIGUOUS?
6. Throughout the history of the NHS politicians,
regardless of political affinity, have emphasised its high ideals.
Their aspirations are for a comprehensive and fair service yet,
despite 50 years of a nationalised service, waiting times are
long and unfair. Aneurin Bevan, Winston Churchill, Margaret Thatcher
and Tony Blair have all reassured the public that access to health
care will be dependent on need and not on the ability to pay.
Their rhetoric is not matched by either policy or practice. This
section examines the policy setting and suggests that there are
two areas where aspiration and policy cannot be squared. Firstly,
from the inception of the NHS, its hospitals have made facilities
and staff available for the treatment of private patients. Secondly,
the NHS permits its key personnel to treat private patients whilst
at the same time exercising no control over the balance of activity
between the two sectors.
(a) A two-tier NHS
7. The opening paragraph of the 1946 National
Health Service Act states that, "It shall be the duty of
the Minister of Health to promote the establishment in England
and Wales of a comprehensive health service." The next paragraph
commences with the self-contradictory statement that: "The
services so provided shall be free of charge, except where any
provision of this Act expressly provides for the making and recovery
of charges." The NHS itself offers a free service for which
some patients are allowed to pay. Since its inception it has always
had private facilities and allowed its surgeons to operate on
private patients in NHS hospitals. It is argued that these are
additional facilities and ultimately save the NHS time and money
in not having to treat patients who would otherwise depend on
the NHS. The contrary view is that the capital stock of facilities
within NHS hospitals has not been funded by the private sector
and is not built into charges; that training costs are not included;
and that there is a constant abuse of the dual system, with private
patients being treated on NHS operating lists.
8. According to Williams, [1] "In 1986,
partly to allay concerns about unjustifiable priority being given
to private patients, the Government published a set of principles
to guide their management [2] which specified that accommodation
and services for private patients should not significantly prejudice
those for NHS patients; earlier private consultation should not
lead to earlier NHS admission nor access to earlier diagnostic
procedures. . ." Subsequently the NHS and Community Services
Act of 1990 [3] re-affirmed that hospitals could provide private
patient accommodation, but with the proviso that NHS contractual
obligations were fulfilled.
(b) Serving two masters
9. Since the establishment of the NHS consultants
have been permitted to work both in the NHS and the private sector.
Throughout most of the history of the NHS there has been a nominal
curb on private practice in the sense that full-time consultants
were not allowed to undertake private practice, above a minimal
amount, without reducing their NHS pay by one-eleventh. For consultants
on ten-elevenths contracts there is no limit to the amount of
private practice that they can undertake. In recent years the
loss of central control over contractual arrangements has led
to some Trusts relaxing these regulations and in some locations
it is now possible for full-time consultants to undertake private
practice without restriction.
10. These various contractual arrangements
place consultants in the invidious position where there is a conflict
of interest. Such conflicts of interest are actively avoided in
both commerce and the public sector. No electricity company official
would expect to retain his employment if he offered to replace
electricity meters in the evening, as a private arrangement, for
an additional cash payment, in the event of the company being
unable to change the meter as quickly as the customer would like.
As one consultant neurosurgeon said in response to the patient
asking whether his BUPA insurance would speed up treatment. "Would
the patient be so casual in offering a bribe if he was speaking
to a police officer instead of an NHS consultant?" [4]
11. Long waiting times are caused by many
factors, including a shortage of resources, inefficiency, and
a lack of clarity over the decision criteria regarding referral
and admission. Not all of these issues are within the control
of consultants, but in some areas of efficiency and decision-making
they have key responsibility and there is a potential conflict
of interest or, as one commentator put it "An invitation
to mischief". [5]
12. Policy in this country is unclear. If
the failure to match aspiration with policy is accidental, there
ought to be the will to change the policy. If the failure is deliberate
then the system might be considered as morally corrupting.
PRACTICE—COMPARING
WAITING TIMES,
WORKLOAD, TIME
AND INCOME
13. In the absence of detailed analysis
of the division of work and time spent in the two sectors, this
section tries to piece together some of the evidence already available.
It examines the differences in waiting times and the division
of workload, time and income between the two sectors. It needs
to be set against the back-cloth that the contractual position
for the majority of consultants (particularly in surgery and anaesthetics)
is based on the maximum part-time contract. This requires consultants
to "devote substantially the whole of their time to hospital
work and to give it priority on all occasions". [6] It also
has to be set against the fact that the reduction of one-elevenths
of the salary would imply a division of time which is 9 per cent
to the private sector and 91 per cent to the NHS.
14. The evidence presented is almost exclusively
concerned with the work of surgeons. Their immediate clinical
workload includes sessions in operating theatres, outpatient clinics
and ward rounds, but their overall duties and responsibilities
are much greater than these three items. They work as part of
a large team and the way in which work is divided differs between
individuals and specialties. Some of their responsibilities are
not directly clinical, but are activities such as teaching and
research. These overlap with their clinical duties and in consequence
are difficult to identify easily.
(a) Evidence about different waiting
times
15. Waiting times for an outpatient appointment
and inpatient treatment vary hugely from town to town, specialty
to specialty, and consultant to consultant across the country.
One consistent feature about waiting times however, is that those
patients who are prepared to pay are treated much more quickly
than those who wait their turn in the NHS. The following are examples.
16. Comparisons between NHS outpatient waiting
times and private sector rooms times were made for orthopaedics
and ophthalmology in 1994. Waiting times for all English NHS clinics
averaged 25 weeks for orthopaedics and 19 weeks for ophthalmology.
In the private sector, sample waiting times averaged two weeks
in both specialties. [7]
17. Waiting times for inpatient and day
case admission are consistently shorter for private patients,
even within NHS hospitals. Williams [1] examined waiting times
over the six year period from 1989-90 to 1994-95. He found that
median waiting times for NHS patients rose from 32 to 42 days,
whilst for private patients it fell from 11 to nine days. For
some operations the contrasts were enormous. In the case of ophthalmic
surgery for prosthesis of lens NHS waiting times averaged 175
days, but for private patients 13 days. One of his conclusions
was that, "In 1994-95, private patients were admitted sooner
than others for operations for potentially serious conditions,
and much sooner for less urgent procedures."
18. It is incontrovertible that private
patients are treated more quickly than NHS patients for similar
conditions. There is also some evidence which suggests that not
only do the rich get treated earlier, but also more often. It
is possible that their easier access might also result in a higher
rate of treatment and one which is not matched to need. Access
to cardiac surgery may be greater for patients in high social
classes, whereas need is greatest in the lower social classes.
[8]
(b) Comparisons of workload
19. A simple comparison of NHS and private
elective inpatient and day case treatment shows that the NHS has
4,349,722 admissions per year compared with 739,810 in the private
sector. [9] The private sector thus undertakes 14.5 per cent of
the total elective volume. The proportion for planned surgical
operations is 13.4 per cent and these figures have remained fairly
constant since 1981. [10] The latest figures for some of the more
common operations are shown in the Table below.
|
| Operation | NHS
| Private Sector |
Total | Percentage
Private Sector
of Total
|
|
| Cataract & lens | 172,203
| 33,976 | 206,179
| 16.5% |
Tonsillectomy &
Adenoidectomy |
87,828 | 11,827
| 99,655 | 11.9%
|
| Drainage of middle ear | 53,074
| 10,803 | 63,877
| 16.9% |
| Operations on coronary arteries | 21,650
| 5,482 | 27,132
| 20.2% |
| Cholecystectomy | 30,652
| 6,463 | 37,115
| 17.4% |
| Abdominal hernia repair | 82,031
| 21,528 | 103,559
| 20.8% |
| Hysterectomy | 59,785
| 10,951 | 70,736
| 15.5% |
| Total hip replacement | 36,894
| 10,707 | 47,601
| 22.5% |
|
Source: Williams et al, 2000 [9].
20. This division of activity does not reflect the true
split of consultant workload between the NHS and the private sector.
In the NHS, whilst the work of junior surgeons is directly or
indirectly supervised by consultants, the actual number of operations
that consultants personally perform, or assist with, is commonly
regarded as something under 50 per cent of the total number of
procedures.
21. Within NHS hospitals private patients are operated
on, almost without exception, by consultants. Some are accused
of giving undue emphasis to their private work in the NHS, but
there is no systematic evidence of this. Illustrations of imbalance
come from NHS staff. One junior anaesthetist cited his experience
of the behaviour of a consultant in the 1980s—"This
surgeon had two or three NHS operating sessions per week and a
healthy private practice. He took about two hours to perform a
total hip replacement and consequently most sessions consisted
of one total hip and a variety of shorter operations. However,
he used to bring his private total hip replacement patients into
the NHS hospital for operations and then transferred then after
a day or so to the private hospital. A large proportion of the
total hip cases operated on at the NHS hospital were private.
You will already have realised that this enabled the surgeon to
operate on many more private patients (as he also operated at
the private hospital) whilst simultaneously extending his already
long NHS waiting list for total hips. [11] My studies of one ophthalmologist's
work at a specialist eye hospital showed that of the 178 operations
he personally performed in one year, in his one NHS operating
list per week at that hospital, 96 were on private patients. These
examples, however, are anecdotal and certainly not representative
of all surgeons.
22. A more systematic attempt was made to study the private
practice and NHS activity of cardiac surgeons in London based
on three studies that used 1992-93 data for all coronary artery
bypass graft (CABG) operations performed inside the M25 ring.
In that year 10,788 CABG operations were performed, of which approximately
4,375 (40 per cent) were on private patients. Of the private patients,
2,480 came from abroad. On the basis of the data generated from
the three studies [12, 13, 14] it was calculated that 60 per cent
of consultant operations were performed on private patients. [7]
The figure for one individual was claimed to be as high as 80
per cent. Other examples include:
23. A specialist orthopaedic hospital performed 1,263
orthopaedic and trauma operations in a three month period. 735
were performed by consultants, of which 321 were on private patients.
25 per cent of the NHS hospital's operations were on private patients
and 44 per cent of consultants' operations were on private patients.
24. A specialist medical oncology hospital with 14,000
first outpatient attendances per annum for NHS patients had over
12,000 first and subsequent private patient attendances in the
same year.
25. Over a six year period one specialist cardiac unit
saw six private outpatients for every 10 new NHS patients.
26. There is evidence that some consultants devote a
disproportionate amount of their attention to private patients.
Individual examples suggest that for some the clinical workload,
as measured by patients seen or treated, might result in private
activity being between 10 per cent and 40 per cent of total volume
for a substantial number of consultant surgeons. However, the
evidence is not systematically gathered and it does not take account
of indirect activities such as teaching, research, management,
on-call duties, etc.
(c) Estimates of time spent in the two sectors
27. Information on the division of time between the two
sectors is restricted to self-reported surveys and investigative
studies of private sector activity. The self-reported studies
undertaken for the Monopolies and Mergers Commission [15] in 1992
reported an average 62 hour working week, of which 11 hours were
spent in the private sector. The study covered just under 3 per
cent of the consultant workforce, but did not provide separate
data specialty by specialty.
28. A more recent confidential study of the workload
of 704 consultant surgeons reported that 34 per cent worked over
48 hours per week on NHS duties, excluding on-call commitments.
[16] The MMC study did not specify what proportion of the hours
spent in the private sector were hours in the normal working week,
but there is evidence that a substantial proportion is spent during
working hours, 9.00 am to 5.00 pm, Monday to Friday. The Norwich
Union study of operating in private hospitals [17] showed that
72 per cent of operating took place during normal working hours.
Studies of private rooms availability [7,18] demonstrated that
the vast majority of rooms sessions (82-94 per cent) were in normal
working hours.
29. These studies showed that the average number of rooms
sessions per week was 1.7, suggesting 5.5 to 6.0 hours per week
set aside for that activity. 36 per cent of consultants had one
rooms session per week, 38 per cent had two sessions per week
and 18 per cent three or more.
|
| Speciality | No of Consultants
| Period | Av No of Private Rooms Sessions
| Range |
|
| T&O [7] | 177
| 1994 | 1.5
| 0-4 |
| Ophthalmology [7] | 66
| 1994 | 2.3
| 0-4 |
| ENT [19] | 25
| 1998 | 1.2
| 0-3 |
| ENT [19] | 27
| 1998 | 1.9
| 0.5-3 |
|
30. Studies of overall time spent in the private sector
have proved difficult to undertake. In 1998, Health Which?
selected a sample of 60 NHS consultants equally divided between
ENT, Ophthalmology and Orthopaedic surgery. In each specialty,
10 consultants were selected with some of the longest and shortest
waiting lists in the country. Researchers posing as the relative
of a patient enquired which days were available for a private
consultation and which days were set aside for private operations.
They found that on average consultants set aside over two half-days
per week for private consultations and operations. [18]
31. In a study of consultant workloads in Trauma and
Orthopaedics [20] consultants were divided into three groups of
low, medium and high workload, based on admission numbers. At
interview, 29 consultants responded to questions about the level
of private sector activity in the working day. The low, medium
and high groups had average figures of 0.9, 1.2 and 1.9 sessions
per week in the private sector. An independent check of these
results was attempted by a telephone enquiry to every surgeon's
secretary. In this case, rooms availability alone was given as
0.8, 0.8 and 1.5 sessions per week. The survey was extended to
a further 29 (non-interviewees) and for similar low, medium and
high workload consultants rooms availability averaged 1.6, 1.4
and 1.3 rooms sessions per week. The results of the survey showed
that most surgeons spent at least one half day per week in the
private sector, a substantial number spent a day a week in the
private sector and for a small number a higher figure still.
32. Job plans and consultant timetables rarely make any
reference to sessional commitments in the private sector. In a
study of 109 orthopaedic surgeons' operating times in one region,
private practice information was only recorded on the job plans
and timetables of 14 of the consultant surgeons. The average number
of sessions per week allocated to the private sector was 1.9.
Four were scheduled to work for 1.5 sessions per week, nine for
2.0 sessions a week and one for 3.0 sessions a week. There is
no way of knowing from these timetables what actual amount of
time was spent in the private sector and whether it was less or
more than the figures cited.
33. A number of confidential studies have been undertaken
because of concerns about certain consultants' commitment to the
NHS. In the 19 cases studied, in five surgical specialties, the
consultants concerned averaged three half-day sessions per week
in the private sector, and seven of them spent four or more sessions
per week in the private sector, all of whom had maximum part-time
contracts.
34. Combining the evidence from various studies [21,22,15,17,23,7]
it appears that about 70 per cent of private practice work is
done during the working week. This represents eight hours, or
one full working day, out of the prime time of the 35 hour working
week (see Table 1 and Figure 1 in Appendix). Given the evidence
available from the Audit Commission's studies of clinic activities
in theatres and outpatient clinics, we are left with the conclusion
that large volumes of non-clinical NHS activity takes place outside
normal working hours. It must be doubtful whether this is the
right time for audit, teaching, administration, research and clinical
governance.
35. The lack of objective evidence about the split in
time between the two sectors is all the more worrying when one
examines the evidence about the operating of Trauma and Orthopaedic
surgeons. This group of consultants, faced with the largest and
longest waiting lists in the UK, are reduced to an average operating
time per week of just seven hours (excluding anaesthetic time).
[24] This data, too often seen as an attack on consultants, is
an indictment of the NHS that fails to use its surgeons effectively.
As the President of the British Orthopaedic Association said,
"Most surgeons would prefer to operate for a minimum of 12
hours a week—surgeons enjoy operating". [25] Given
such low levels of operating, the time has come to examine how
the other 50 hours per week are spent, be they in the NHS or the
private sector.
(d) Evidence about the split of income
36. In 1997-98, over 50 NHS Trusts each had a private
sector income that exceeded £1 million per annum. [26] In
some cases the level of income is substantial in proportion to
the NHS budget and risks skewing the priorities of the hospital
when negotiating its workload. This can be particularly the case
for single specialty hospitals and regional centres.
37. Studies of consultants' earnings have been made by
the Monopolies and Mergers Commission in 1992 and by the Inland
Revenue in 1986-97, 1991-92 and 1993-94. NHS earnings are basically
the same regardless of specialty and differ between consultants
only on the basis of years in post and the level of merit award
payments. Private sector income varies depending on the level
of demand and the time each consultant is prepared to devote to
private work. There is consistent evidence that some specialties
have a greater level of earnings than others. [15] In particular,
surgical specialists and anaesthetists tend to earn more than
medical specialists. The higher earners are mostly to be found
amongst the 5,000 or so consultant surgeons and 1,000 anaesthetists
rather than the remaining 15,000 consultants.
38. The Inland Revenue studies of all consultants' earnings
revealed that by 1993-94, 49 per cent of maximum part-time consultants'
earnings was from private practice. This means that for the majority
of surgeons and anaesthetists much more than half of their income
is generated from the private sector. This evidence can be used
to support the argument that NHS salary levels are too low.
39. Those figures suggest that surgeons have little financial
incentive to work in the NHS. An NHS post is merely needed to
generate private work and to provide a pensionable base. The financial
dilemma faced by consultants is illustrated by conversations with
three surgeons in recent months. The first was a consultant who
does no private practice but merely does medico-legal work on
Saturday mornings. This work alone enables him to double his NHS
salary. The second example is a surgeon who operates on three
mornings per week and has three afternoon clinics per week in
the NHS. In the remaining two days he undertakes private work
for which he earns £3,000 a day. He explained to me that
he was reluctant to undertake a further NHS operating list but
would be prepared to do so if the NHS would pay him an additional
£1,500 per half day. The third discussion was with a consultant
cardiac surgeon in London regarding the suggestion that private
work should be separated from the NHS and that consultants should
be required to work in either one sector or the other. He explained
that, given an income of one third of a million pounds per annum
from the private sector, it would not take him too long to make
his decision about which sector to work in.
40. The division of earnings between the NHS and the
private sector for the average consultant is split 50:50, but
for surgeons the proportion is generally much higher in terms
of earnings from the private sector.
To summarise the evidence, we find:
41. waiting times for private patients are always shorter
than for NHS patients;
42. the consultants' contract requires them to devote
substantially the whole of their time to the NHS and possibly
implies that no more than 10 per cent of working time should be
devoted to the private sector;
43. work activity as measured by operations performed
suggests that 10-40 per cent of the workload is committed to private
practice;
44. estimates of time devoted to the private sector suggests
that 20 per cent of the normal working week is devoted to the
private sector;
45. earnings data shows that at least 50 per cent of
earnings comes from the private sector for the average consultant,
and that for surgeons this figure is considerably higher.
46. The current division of activity and time is highly
likely to be influenced by the perverse incentive of financial
reward being much greater for one sector than the other. This
places an enormous and almost immoral pressure on consultants
and their families.
INERTIA OR
CHANGE?
47. There is considerable timidity in approaching this
sensitive issue. Successive governments and the Department of
Health have consistently evaded calls to study the interface between
the NHS and the private sector.
48. In 1990 the Public Accounts Committee tried to ascertain
how much time it would be reasonable for a consultant to take
off from the NHS in order to undertake private practice and in
its formal report stated, "We believe that health authorities
need a more accurate picture of the total level of consultants'
commitments to ensure that their responsibilities for the treatment
of patients are not put in jeopardy through working excessive
hours. [27]
49. In the following year the House of Commons Health
Committee recommended, ". . . that the Department of Health
carry out a study . . . to try and determine the influence, either
positive or negative, that private practice in the same unit or
specialty has on the waiting list and waiting time for treatment.
The results of such a survey should help inform districts in their
local discussions of consultants' job plans". [28] In the
same year the Welsh Affairs Committee of the House of Commons
concluded, "We agree with the Health Committee that the influence
of private practice be examined". [29]
50. In 1995 the Labour Party set out its agenda for a
healthier Britain and commented, "Private medicine has come
to play an increasing role as the government has sought steadily
to erode the NHS. The balance between public and private medical
provision is one that has to be examined carefully to ensure that
the use of NHS premises and resources is adequately recompensed
and that there are no consequential adverse impacts on waiting
times for NHS patients. The government has ignored the recommendations
of the House of Commons Health Select Committee in 1991 that,
`the Department of Health carry out a study to try and determine
the influence, either positive or negative, that private practice
in the same unit or specialty has on the waiting list and waiting
time for treatment'. Labour will act on this recommendation".
[30] It has not yet done so, despite a further call from the Independent
Inquiry into Inequalities in Health [31] which recommended establishing
a review of the relationship of private practice to the NHS with
particular reference to access to effective treatments, resource
allocation and availability of staff.
51. A decade ago it was argued that the uncertainty around
this issue would be clarified through the introduction of "job
plans" for consultants. In fact, the job plans have made
little difference to the inequity that exists as far as patients
are concerned. Since their introduction it has become commonplace
to see Trusts accepting that consultants should spend two half
days a week in the private sector, whereas prior to their introduction
one session per week was the norm. We must be careful to ensure
that the optimistic claims about the value of job plans are not
repeated with vague promises about the potential impact of the
re-negotiation of consultants' contracts. If this nation wants
access to hospital care to be available on the basis of need,
it has to wholeheartedly address the loosely worded legislation
of 1946 and the political fudge surrounding the consultants' contract.
Both provide a conflict of interests that patients find unacceptable.
As the Secretary of State said on 18 May this year, "There
will be tough decisions to be made, decades-old shibboleths to
be laid, it will require the courage to change by members of the
Government as much as members of the Royal Colleges". [32]
NEXT STEPS
52. Two of the possible reactions to this paper are either
that more evidence is required, or that action is required to
remove the conflict of interests that is associated with inequitable
waiting times. If further evidence is required this cannot simply
be based on the opinions of politicians, civil servants, managers,
surgeons and patients. It requires the gathering of detailed data
about the patients treated in both sectors. The data needs to
be linked together at consultant level and ought to be collected
for a minimum period of three months, preferably for a full year.
Any prospective study should be matched by a retrospective analysis
of data to ensure that the prospective study was reasonably representative.
53. If it is thought that action is required the two
most obvious solutions are either to completely separate NHS and
private sector activity, not allowing consultants to work in the
two sectors simultaneously, or alternatively to exercise tighter
and more systematic control on private sector activity within
the NHS.
54. The case for suggesting a complete separation of
private and NHS work is in part based on the fact that today consultants
face an increasing level of pressure of the sort never experienced
before. The demands of an ageing population, the reduction in
junior working hours and increased responsibilities for clinical
governance add pressure to the demands of research, teaching,
audit and clinical work. This is not work that should be squeezed
into evenings and weekends and four or so half-day sessions competing
with the demands of on-call commitments and time spent in the
private sector. It is a job that demands highly skilled professionals
and requires their full attention. They should not be forced to
divert their attention to the private sector simply to increase
their income to a reasonable level. By most standards the basic
consultant pay must be seen as unreasonably low. The financial
position now facing the NHS gives an opportunity to increase the
take-home pay of consultant surgeons and anaesthetists. Such a
solution will not be easily negotiated for those consultants whose
income outside the NHS adds £100,000 or more to their annual
income. The process could, however, be staged and increasingly
reward those who devote the whole of their time to the NHS.
55. A second course of action would be to exercise extremely
tight control on private sector activity within the NHS that guarantees
private patients are not treated earlier than NHS patients. Guidelines
could be introduced that would not permit hospitals or surgeons
to undertake private practice unless outpatient waiting times
were less than four weeks for routine appointments, all inpatients
were treated within three months, and that certain minimum workload
standards were attained.
56. The results of such changes should be measured in
terms of improved equity of access and not in terms of changes
in levels or distribution of activity. Patients want a fair National
Health Service, where they can receive care on the basis of need
rather than the ability to pay. Any actions taken should be measured
against that criterion.
5 June 2000
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